Provider Demographics
NPI:1568087641
Name:BOLTON, TIFFANY MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:BOLTON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3516 MAINE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-1154
Mailing Address - Country:US
Mailing Address - Phone:714-791-9156
Mailing Address - Fax:
Practice Address - Street 1:8327 RESEDA BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-4620
Practice Address - Country:US
Practice Address - Phone:818-718-8450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-14
Last Update Date:2020-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001344367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered